Quality Management

Clinical Protocol Development

Protocols are essential to reduce variation in
diagnosis and treatment, thereby ensuring high "quality":

Two patients in the same clinic. Same problem. Same symptoms. Different
doctors beget different treatment plans. Two different charges. Why?

Employers and payors want to know. Unfortunately, while many healthcare
providers boast a lot about quality, few measure their performance
either on clinical outcomes and customer satisfaction. Fact: If you're
not collecting and reporting data, you have no business talking about
quality. Part of the problem is that those in healthcare do not understand
the true definition of quality. Quality is defined as the reduction
of variation about the mean. In automotive, that can mean making sure
the distance between a fender and hood is 2 millimeters with a maximum
deviation of 1 millimeter.

As part of a comprehensive quality management program, Prizm helps
quality-minded healthcare companies, hospitals, and physician group
practices reduce treatment variation through written clinical protocols
and pathways that standardize how all physicians in a practice triage
and treat patients. True, the benefit of a pathway is quality. But
there is a bigger financial benefit as well. By developing consistent
treatment guidelines, Prizm can then create case rate packages that
cover a month-long episode of care at an attractive, predictable price
for managed care.

Case rate packages
are a win-win arrangement for the provider and the payor

Prizm, for example, has successfully contracted with several managed
care companies using Prizm's case rate methodologies. Instead of getting
reimbursed on a CPT-code basis, Prizm clients can be reimbursed on
an ICD-9 code basis. The approach is desirable to managed care because
it addresses the quantity of units consumed. For instance, even austere
discounts merely reduce the price for a physician office visit, or
a PT visit. But such discounts do not control the number of times that
CPT code is billed.

Case rate packages for a "episode of care" are a win-win
for the quality-oriented provider and managed care payor. In this way,
the provider is rewarded for its efficiency, rather than punished for
it. That's because the best providers will reduce the number of units
provided to the best case scenario.

By using protocols, a center is positioned
to provide a predictable price to a payor, thereby getting
off the slippery slope of continual discounts against RBRVS.

Prizm's proprietary protocols enable a spine center to sort back pain
patients into price-predictable categories. Prizm invested more than
$50,000 on statistical analysis that evaluated means and standard deviations
for spine ICD-9s. A spine center can price for an episode of care for
physician visits, diagnostics and therapy. Prizm has contracted successfully
with a variety of carriers. Without such tools, a spine center would
be economically punished for providing conservative care, because it
will have fewer CPTs to bill.

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